Wednesday, May 15, 2013

So…What happens next?

The idea that we’re on the cusp of a major
paradigmatic shift in our thinking about psychiatric disorders is gaining
ground. The proposed revision of the American Psychiatric Association’s
Diagnostic and Statistical Manual (DSM) of Mental Disorders franchise
– DSM-5 – has prompted world-wide debate
and discussion. The debates have identified
serious inadequacies in the specific proposed revisions, and have also
highlighted scientific, philosophical, practical and humanitarian weaknesses in
the diagnostic approach and ‘disease model’ of psychological well-being that
underpins the DSM (and ICD) franchise.

Diagnosis is Failing…

Many of us have highlighted the
poor reliability, validity, utility, epistemology and humanity of psychiatric
diagnoses. Psychiatric diagnoses fail to map onto any entity discernable in the
real world, fail to predict the course of a person’s problems and fail to
indicate which treatment options are beneficial. Psychiatric diagnoses do not
map neatly onto biological findings, which are often nonspecific and cross
diagnostic boundaries. So psychiatric diagnoses fail basic tests of science.
They also have ethical failings. Diagnoses convey the idea that people’s
difficulties can be understood in the same way as bodily diseases, and are used
as pseudo-explanations for troubling behaviours.

These worries are catalyzed by
the proposed revisions to DSM-5. These include a lowering of a swathe of
diagnostic thresholds, which will inflate the assumed prevalence of mental
health problems in the general population, continue to medicalise a range of
normal social and interpersonal problems and see an increased emphasis on the
supposed biological underpinnings of psychological distress. So, for example,
we saw the proposal that grief, in essence, be pathologised. And, as if to drive the worries
home, as the debate over DSM-5 gathered pace, we learned not only that 70% of
the task force responsible for revising DSM-5 had financial links to pharmaceutical industry,
entirely unsurprisingly – but also that physicians had already developed
specific pharmaceutical products designed to “treat”
grief.

This is dramatic news indeed.
When the world’s largest source of funds announces that it’s lost faith in the
world’s dominant psychiatric diagnostic scheme, something serious is happening.
But it is also complex, and there’s still a significant debate to be had as to
where we should go next. Many of the opponents of traditional psychiatric diagnoses complain that
they place too much emphasis on biomedical factors and the attempt to emulate
medical diagnoses. Instead, these critics argue, mental health care needs to
place more emphasis on normality (not pathology), on social factors in the
origin of mental health problems (rather than supposed biological causes), and
on the need for psychosocial interventions (rather than medication). NIMH,
however, has suggested exactly the opposite – that a greater emphasis on
biomarkers and the relationship between biological processes and the
identifiable problems that people report was a necessary basis for progress.

So…What Happens
Next…?

In my opinion, we need a
wholesale revision of the way we think about
psychological distress. We should start by acknowledging that such
distress is a normal, not abnormal, part of human life – we respond to
difficult circumstances by becoming distressed. That does mean that there’s a
problem to be solved, and a demand for help and assistance, but it doesn’t mean
there’s a necessary pathology. We should also acknowledge that all human
emotions, behaviours and thoughts depend on our brains – and our brains are of
course biochemical engines ultimately dependent on our genetic inheritance. But
that simply doesn’t mean that differences between us depend on biological differences;
in fact it’s much more likely that individual differences owe more to
circumstances than biology. For example, there’s very strong evidence
that psychosocial factors such as poverty, unemployment and trauma are
significant causes of psychological distress although, of course, genetic and
developmental factors may influence how we react to these kinds of challenges.
And finally, we should recognize that there is no easy ‘cut-off’ between
‘normal’ experience and ‘disorder’.

Problem List and
Formulation

For me, the obvious alternative
to psychiatric diagnosis is a very straightforward combination of a problem
list and psychosocial case formulation.

All decent mental health
professionals will guide their care of their clients on the basis of more than
a diagnosis (one of the other reasons why they are fundamentally flawed), and
so the idea that we should come up with a case formulation – a set of working
hypotheses about what might link the person’s problems, what might have caused
them, and what might help – is not radical.

Some international effort will be
needed to develop a shared lexicon, but it is relatively straightforward to
generate a simple list of problems that can be reliably and validly defined;
for example, depressed mood, auditory hallucinations and intrusive thoughts.
These aren’t – I must stress – alternative diagnoses. We do not have to assume
that these problems co-vary as a consequence of underlying ‘illnesses’ (although,
equally, there is no reason to exclude this possibility). There is no reason to
assume that these phenomena cluster into discrete categories or other simple
taxonomic structure. And we absolutely don’t have to assume that these problems
are caused by underlying biological pathologies.

Proponents of diagnosis assume
that such classifications are needed for communication between professionals,
the planning of services, and – at least in the US – billing for services. But,
of course, it’s perfectly straightforward for all kinds of services to plan,
commission and (in those unfortunate nations that have not yet evolved
socialized healthcare) bill for services on the basis of the identified
problems and the services needed to put them right. As with many other areas of
medicine, social services and wider civil society, professionals can
communicate both between themselves and with their clients simply by saying
what’s wrong, what the cause might be and what they suggest might be the best
response. We don’t use diagnoses in other areas of public life, and we
shouldn’t in what are, essentially, social and emotional problems.

Of course, traditional
psychiatrists, and many members of the public, say that they find a diagnosis
helpful and even comforting. But the truth is that this comfort comes from
knowing that your problems are recognised (in both senses of the word),
understood, validated, explained (and explicable) and that the person you’re
speaking to has a decent plan to help you. A problems list and a formulation
can do that. Paradoxically, better than a diagnosis – since, for example, two
people with a diagnosis of ‘schizophrenia’ or ‘personality disorder’ might have
absolutely nothing in common, not even the same ‘symptoms’, any comfort from a
diagnosis is likely to be illusory.

So, instead of re-inventing the
biomedical DSM and ICD franchise, and instead of heading down an NIMH dead-end,
we should encourage clinicians, working in multidisciplinary teams, to develop
individual formulations consisting of a summary of an individual’s problems and
circumstances, hypothesis about their origins and possible therapeutic
solutions. This ‘problem definition, formulation’ approach rather than a
‘diagnosis, treatment’ approach would yield all the benefits of the current
approach without its many inadequacies and dangers.